Atypical Cavitary Lung Lesions

icine- O Gerada et al., Intern Med 2014, 4:1 ed pe M n l A a c DOI: 10.4172/2165-8048.1000131 n c r e

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s n I Internal Medicine: Open Access

ISSN: 2165-8048

Case Report Open Access Atypical Cavitary Lung Lesions: A Case Report and Review of Radiologic Manifestations Eleanor Gerada1*, Noel Gatt2, Adrian Mizzi3 and Stephen Montefort1 1Department of Medicine, Mater Dei Hospital, Malta 2Department of Pathology, Mater Dei Hospital, Malta 3Departmnt of Radiology, Mater Dei Hospital, Malta

Keywords: Lung cavity; Pulmonary metastasis; Aspergillosis; Discussion Endometrial carcinoma; Hormonal therapy A cavity is a‘lucency within a zone of pulmonary consolidation, Case Report a mass, or a nodule; that is surrounded by a wall, usually of varied thickness [1]. Non-infectious causes of cavitation include malignancy, A 68-year-old woman presented to our emergency department inflammatory conditions (e.g. rheumatoid, sarcoidosis and Wegener’s with a 15 day history of epigastric discomfort radiating to the back. She granulomatosis), pulmonary infarcts, and other miscellaneous causes had undergone a hysterectomy with bilateral salpingo-oophorectomy such as cryptogenic organising pneumonia and Langerhans’ cell ten years before, for a FIGO stage 1 endometrioid adenocarcinoma. histiocytosis [2]. Primary lung cancers tend to form cavities more often While abdominal examination was unremarkable, her liver function than pulmonary metastases do. 22% of primary lung cancers [3] and tests showed a cholestatic picture. An ultrasound scan of the abdomen 4% of pulmonary secondary cavitate, 69% of these are squamous cell revealed several gallstones as to the cause of this pain. Incidentally on carcinomas [4,5]. Pulmonary metastases commonly result from the chest radiograph, several lung lesions were noted bilaterally (Figure breast, colon, skeletal or urogenital systems. They usually only cause 1). On further questioning, the lady admitted to a one-year history of symptoms if metastatic tumour growth occurs endobronchially [6], as asthma with cough during the day and exertional dyspnoea. Inhaled is the case with our patient. Endobronchial metastases were causing a corticosteroids prescribed for her ‘asthma’ proved to be ineffective. cough which was misdiagnosed as asthma. She was a non-smoker. She denied other respiratory symptoms, night Cavitation can be either spontaneous or therapy-induced; of which sweats, chills, rigors or weight loss. She managed a good appetite and both chemo- and radio-therapy are known culprits. Spontaneous a good exercise tolerance for her age. There was no history of old TB, cavitation occurs by one of two mechanisms: i) either the tumour recurrent chest infections, recent travel or the presence of any mould outgrows its blood supply with resultant central necrosis, or ii) a check at home. valve mechanism [3]. Cavitation of pulmonary metastases occurs more The findings in her chest were completely normal as was the rest of her examination. She had a total white cell count of 8.7 × 109/L and an eosinophil count of 0.07 109/L. ESR was 42 and CRP was 23. A contrast-enhanced CT scan revealed multiple thin-walled cavities, most containing a soft tissue attenuation mass, in some cases with an air crescent sign. No halos of ground glass opacification surrounded these lesions (Figure 2). A radiological diagnosis of invasive aspergillosis was thus made. Serum galactomannan antigen test however resulted negative. During bronchoscopy the posterior segment of the right upper lobe appeared to be infiltrated by tissue bearing prominent vascular markings (Figure 3a); the lumen of the right middle lobe was partially occluded by an intraluminal mass (Figure 3b). This intraluminal lesion bled easily on minimal contact. Cytology from lavage and brushings was negative. Culture was negative, and no fungal elements were seen. A repeat bronchoscopy unfortunately yielded no new information. Figure 1: Postero-anterior CXR view showing multiple round lesions A CT-guided lung biopsy of a cavitating lesion was thus performed. bilaterally. The lesion in the middle lobe of the right lung was chosen for sampling. The biopsy samples almost completely consisted of complex epithelial glandular proliferation. There was very mild nuclear atypia, almost *Corresponding author: Dr. Eleanor Gerada, Mater Dei Hospital, Msida, MSD no mitotic activity and complex architectural features such as rigid 2090, Malta, Tel: 0035625457570 / 0035679884822; Fax: 0035625457582; E-mail: cribriform spaces and nuclear stratification (Figure 4a). The tumour [email protected] cells stained for CK7 and ER (Figure 4b) and were negative for CK20, Received October 24, 2013; Accepted December 27, 2013; Published January TTF-1, p63 and CDX-2. These suggested a metastatic endometrial 05, 2014 adenocarcinoma. Citation: Gerada E, Gatt N, Mizzi A, Montefort S (2014) Atypical Cavitary Lung Hormonal therapy was the modality opted for, and 3 months after Lesions: A Case Report and Review of Radiologic Manifestations. Intern Med 4: 131. doi:10.4172/2165-8048.1000131 starting medroxyprogesterone acetate, the lesions had completely disappeared on chest radiograph. Fourteen months have passed Copyright: © 2014 Gerada E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted since, and there has been no recurrence of either the cough or of the use, distribution, and reproduction in any medium, provided the original author and radiological findings (Figure 5). source are credited.

Intern Med Volume 4 • Issue 1 • 1000131 ISSN: 2165-8048 IME, an open access journal Citation: Gerada E, Gatt N, Mizzi A, Montefort S (2014) Atypical Cavitary Lung Lesions: A Case Report and Review of Radiologic Manifestations. Intern Med 4: 131. doi:10.4172/2165-8048.1000131

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Wall thickness between 5 to 15mm can be either benign or malignant. If the thickness is more than 15mm, the cavity is usually malignant. However, thin walled cavities can still be seen with metastases from adenocarcinomas and sarcomas. Cavities in Wegener’s granulomatosis can have irregular thick walls and thus it can be difficult to differentiate these from malignant cavities. The ‘air-crescent sign’ is generally a sign of an inflammatory process such as aspergillosis. Likewise; lung malignancy, tuberculosis and Wegener’s granulomatosis can exhibit this sign too. One must also keep in mind the possibility of mycobacterial or fungal pathogens coexisting in malignant cavities [3]. A distinguishing feature between a malignant cavity and an aspergilloma, is that in malignancy the soft tissue lesion within the cavity, usually enhances with contrast. On the other hand, an aspergilloma exhibits a dependent location and adjacent bronchiectasis [8]. Ground glass opacification surrounding a nodule also known as the ‘halo sign’ is quite specific for Figure 2: CT scan images showing multiple thin-walled cavities, most aspergillosis. However, this has been also noted in some patients with containing a soft tissue attenuation mass, in some cases with an air crescent sign. No halos of ground glass opacification are seen around these lesions. pulmonary metastases, where it signifies peri-tumoral haemorrhage [3]. Despite having visualised endobronchial metastases in this patient, cytology was negative. A study on cavitary pulmonary metastases had showed lack of positive bronchial biopsies in all the patients with occluded bronchi secondary to endobronchial metastases [9]. In our case, radical treatment had been performed 10 years prior to the disease metastasising. She had been followed up for 6 years without disease recurrence. In the literature, only 2 cases report a longer interval from radical treatment of endometrial carcinoma to recurrence in the a b lung, that of 17 years; both of which had non-cavitating metastases. Figure 3: Bronchoscopy images showing: a) Posterior segment of right upper Nonetheless the histology of the first case was of the adeno-acanthoma lobe bronchus appears infiltrated b) Mass obstructing sub-totally the right type, with a solitary lung lesion that was amenable to resection [10]. middle lobe bronchus. The second case was an endometrial endometrioid adenocarcinoma metastasising to the lung as a large mass with satellite nodules [11]. Patients with low-grade metastatic endometrial carcinoma that are oestrogen-receptor positive, tend to respond as well to hormonal therapy as to cytotoxic chemotherapy, with fewer side-effects and lower morbidity. Trials demonstrate a progression-free interval of 4 to 6 months with medroxyprogesterone acetate [12]. The median interval from detection of lung metastases from endometrial carcinoma to death is only 5 months. 80% of patients usually succumb to the disease a b Figure 4: a) Metastatic adenocarcinoma with irregular glandular outlines and rigid cribriform spaces with a hint of squamous metaplasia. b) Diffuse ER staining and strong nuclear positivity. commonly in the upper lobes, [4] and the location of the cavity is more often central [7]. The case we report clearly shows that metastases can exhibit unusual radiological features that make discrimination from other non- malignant pulmonary diseases difficult. Unusual features can include cavitation, calcification, peri-nodular haemorrhage, air-space pattern, pneumothorax, tumour embolism, solitary mass, endobronchial metastases, and dilated vessels within mass and sterilized metastases. The incidence of visible endobronchial metastases in the major airways is only 2%. The most common radiologic appearance is atelectasis of the corresponding lobe [5]. Features of a cavity suggestive of malignancy comprise of i) cavity wall thickness at its thickest section, and ii) irregular inner and outer Figure 5: CXR taken 3 months after starting methylprogesterone acetate. margins. A cavity with a wall thickness of ≤ 4mm is usually benign.

Page 3 of 3 within 12 months of diagnosis [10,12]. In our case, 14 months after 5. Seo JB, Im JG, Goo JM, Chung MJ, Kim MY (2001) Atypical pulmonary detection of lung metastases, the patient is still progression-free with metastases: spectrum of radiologic findings. Radiographics 21: 403-417. the aid of hormonal therapy. The chest radiograph is free from lesions. 6. Dinkel E, Mundinger A, Schopp D, Grosser G, Hauenstein KH (1990) Diagnostic imaging in metastatic lung disease. Lung 168 Suppl: 1129-1136. The spectrum of radiological findings in pulmonary metastases is 7. Takashima S, Morimoto S, Ikezoe J, Arisawa J, Hamada S, et al. (1989) broad. A histo-pathological diagnosis allows an accurate diagnosis of [Cavitating malignant neoplasms in the lung]. Rinsho Hoshasen 34: 45-50. metastases from non-malignant pulmonary diseases to be made. An 8. Park Y, Kim TS, Yi CA, Cho EY, Kim H, et al. (2007) Pulmonary cavitary early diagnosis of lung metastases may be critical in planning effective mass containing a mural nodule: differential diagnosis between intracavitary therapy. aspergilloma and cavitating lung cancer on contrast-enhanced computed tomography. Clin Radiol 62: 227-232. References 9. Chaudhuri MR (1970) Cavitary pulmonary metastases. Thorax 25: 375-381. 1. Tuddenham WJ (1984) Glossary of terms for thoracic radiology: recommendations of the Nomenclature Committee of the Fleischner Society. 10. Ito H, Nakayama H, Noda K, Mitsuda A, Kameda Y, et al. (2001) A case of lung AJR Am J Roentgenol 143: 509-517. metastasis from endometrial adenoacanthoma 17 years after initial treatment. Jpn J Clin Oncol 31: 337-340. 2. Gadkowski LB, Stout JE (2008) Cavitary pulmonary disease. Clin Microbiol Rev 21: 305-333, table of contents. 11. Miyamoto H, Jones CE, Raymond DP, Wandtke JC, Strang JG, et al. (2009) Pulmonary metastases from uterine neoplasms after long tumour-free interval: 3. Gill RR, Matsusoka S, Hatabu H (2010) Cavities in the Lung in Oncology four cases and review of the literature. Pathology 41: 234-241. patients: Imaging overview and differential diagnoses. ApplRadiol 39 :10-21 12. Temkin SM, Fleming G (2009) Current treatment of metastatic endometrial 4. Cavitary Pulmonary Metastases. Learning radiology recognizing the basics cancer. Cancer Control 16: 38-45.

Intern Med Volume 4 • Issue 1 • 1000131 ISSN: 2165-8048 IME, an open access journal